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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202655
Report Date: 07/24/2024
Date Signed: 07/25/2024 08:28:13 AM

Document Has Been Signed on 07/25/2024 08:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MARQUEZ LIVING I (RCFE)FACILITY NUMBER:
435202655
ADMINISTRATOR/
DIRECTOR:		MARQUEZ LORENZO, MARIAFACILITY TYPE:
740
ADDRESS:994 SOBRATO DRTELEPHONE:
(408) 533-2829
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 14CENSUS: 12DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator, Josephine YongTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator (ADM) Josephine Yong and stated the purpose of today's visit. LPA Rai spoke with Licensee/Administrator Maria Marquez Lorenzo and stated the purpose of today's visit and verified she is overseeing the facility while there is a change of ownership to another licensee.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply for at least 2 days of perishable food and at least 7 days of nonperishable food. LPA Rai observed a key pad lock on the kitchen door wherein staff punched in the number code and opened the kitchen door. ADM stated they wanted to secure the kitchen and at this time, there was no concern of resident's allergies and concerns of residents having access to sharp objects, such as knives and chemicals since both were locked separately in different cabinets in the kitchen. LPA Rai observed water dispenser in the dining room for residents to access water. During visit, staff S1 removed the key pad lock and placed a regular door handle on the kitchen door. LPA Rai observed the kitchen door had regular doorknob with key lock and advised 2 facility staff (S1-S2) in the kitchen and ADM the door cannot be locked. S1, S2 and ADM agreed and understood.

LPA Rai randomly toured 10 resident bedrooms. 10 Out of 10 resident bedrooms had available bedding, drawers, and functioning lights. 7 Out of 12 residents have half bed rails attached to the bed. 3 Out of the 7 resident having half-bed rails are receiving Hospice services and ADM removed 1 resident's half bed rails since resident does not need half bed rail for mobility. During visit, 2 out of 12 residents had half bed rails that resident use for mobility and did not have a signed physician's order for the half-bed rail. LPA Rai advised ADM that the half bed rail is not to be used as a restraint or safety for fall precautions. ADM stated she agreed and understood. ADM is working with resident's responsible party to obtain a signed written order from physician for half-bed rail to be used as mobility. Continuation on LIC 809-C, Page 1 of 4.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MARQUEZ LIVING I (RCFE)
FACILITY NUMBER: 435202655
VISIT DATE: 07/24/2024
NARRATIVE
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Page 2 of 4.

LPA Rai observed 3 out of 3 resident bathrooms had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 114.3 degrees F - 118.4 degrees F. A resident bathroom located in a resident room wherein 2 residents were sleeping in bed had a tile lifting from the floor. The tile lifting was causing an outward bump wherein LPA Rai observed the floor was not smooth and may potentially be a fall risk hazard and not to be in good repair. ADM stated the staff did not observe the tile lifting from the floor. ADM stated the hot weather in the past couple of days may have caused the tile to lift since the tile has glue on one side which helps the tile stick to the floor. LPA Rai observed a power outlet without cover and exposed wires in the wall of the same bathroom. ADM stated the bathroom was recently painted and they forgot to put the cover on the power outlet.

During visit, LPA Rai observed resident R1 sitting in the common room with urine bag attached to the leg. LPA Rai verified with ADM if R1 is physically and mentally capable of caring for all aspects of the condition except insertion and irrigation. ADM stated the staff needs to assist R1 with emptying the bag. ADM stated they received verbal instruction from the Home Health Agency but does not have written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed.

Fire extinguisher was observed and inspected on 05/29/2024. Facility smoke detectors and sprinklers were in working condition and inspected by a third party vendor on 6/3/2024. The last disaster drill was conducted on 01/02/2024 and facility cares and supervises residents with Dementia diagnosis. ADM stated she plans on conducting a disaster drill soon but the last one conducted was 01/02/2024.

LPA Rai reviewed facility records for 4 staff. LPA Rai observed the staff records were complete, but there were no records of staff training for 2024. ADM stated Licensee/Administrator Maria Marquez Lorenzo removed the records and there were no records on staff training at the facility. ADM could not access any online training and has not conducted training with the staff at this time.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MARQUEZ LIVING I (RCFE)
FACILITY NUMBER: 435202655
VISIT DATE: 07/24/2024
NARRATIVE
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Page 3 of 4.

LPA Rai reviewed 3 out of 4 staff which were hired this year and ADM did not have initial training records at the facility. ADM stated Licensee/Administrator Maria Marquez Lorenzo has staff training records with her and those records are not at the facility. ADM stated Licensee/Administrator Maria Marquez Lorenzo came into the facility and provided initial and shadowing training to the new staff. LPA Rai stated per Title 22 regulations, Licensee shall maintain in the personnel records verification of required staff training and orientation. ADM agreed and understood.

LPA Rai reviewed facility records for 4 residents. LPA Rai reviewed resident R2's current and PRN medications and central stored medication records. ADM stated R2 was being administered 7 medications. R2 moved into the facility on 6/7/2024 and ADM stated 5 out of 7 medications were provided to the facility staff when resident moved into the facility. ADM stated the facility staff did not obtain refill R2's medications until after R2's case manager was informed on 6/18/2024 when ADM reached out to R2's case manager via text message requesting refill. ADM showed LPA Rai R2's bubble pack filled with 4 medications which was filled on 6/12/2024 and had 30 days of supply. ADM stated the last dose of the medication was administered yesterday 7/23/2024, but R2's Centrally Stored Medication log did not contain the "start date" for the 4 medications.
Based on record review of the bubble pack, medication #1 was divided into two bubble packs with 60 tablets total for 30 days supply of medication and the order on the prescription stated the medication needs to be given 1 tablet twice a day. Per ADM, the last dose of the bubble pack was given yesterday 7/23/2024 and based on medication count of the bubble pack, the facility staff would have started the medication on 6/24/2024. Per R2's Centrally Stored Medication log, the start date was not filled which would indicate when the medication was initially administered. Based on medication count, medication #1 was not administered to the resident from 6/7/2024 - 6/24/2024 due to medication #1 was not included in the medications R2 brought during move in day. ADM stated a new bottle of medication #1 is available to use today and will be administered today. LPA Rai reviewed resident file and there are no physician's order for medications which have been administered to the resident and ADM was not aware the facility needed to retain physician's orders for medications since ADM was administering medication based on the prescription order on the medication bottle.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MARQUEZ LIVING I (RCFE)
FACILITY NUMBER: 435202655
VISIT DATE: 07/24/2024
NARRATIVE
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Page 4 of 4.

LPA Rai and ADM reviewed R2's medication #2 where resident is being administered 2 tablets twice a day and the bottle was opened and medication administration stated on 7/9/2024. Based on the medication count, LPA Rai and ADM counted the medication twice and both times the medication count was 11 tablets. Based on the order on the medication bottle, the resident should have been given 30 tablets, therefore there is 1 extra tablet in the medication bottle. ADM stated R2 did go to the hospital on 7/9/2024, and LPA Rai observed the After-Visit Summary and R2 was prescribed the medication #2 during the hospital visit. ADM stated the facility staff did not document if and when R2 went to the hospital or refused medication. ADM did not count the medication when medication bottle was delivered to the facility.

87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs, such as administer medication to residents in care.

ADM stated to LPA Rai that she was "vaguely familiar with Title 22" and did not receive complete training for Administrator Certification a year ago. LPA Rai stated it is the responsibility for the Licensee and the Administrator to have knowledge of and ability to conform to the application laws, rules and regulations, which includes Title 22.

Deficiencies were cited per California Code of Regulations, Title 22 during today's visit. Technical Assistance was provided.

Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator (ADM) Josephine Yong and a copy of the report was provided. Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 07/25/2024 08:28 AM - It Cannot Be Edited


Created By: Simranjit Rai On 07/24/2024 at 04:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARQUEZ LIVING I (RCFE)
FACILITY NUMBER: 435202655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2024
Section Cited

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87465 Incidental Medical and Dental Care (a)(5)(A) Medications usually prescribed for self-administration which have been authorized by the person's physician.
This requirement is not met as evidenced by:
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Based on record review, interview and observation, resident R2's 7 medications did not have a signed physician's order for facility staff to administer the medication to R2 which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
07/25/2024
Section Cited

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87465 Incidental Medical and Dental Care (h)(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...
This requirement is not met as evidenced by:
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Based on record review, interview and observation, resident R2's Centrally Stored Medication Log had multiple medications wherein "start date" was not filled and ADM could not verify if medication was administer to R2 which poses/posed a immediate health, safety or personal rights risk to...
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 (con't) persons in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 07/25/2024 08:28 AM - It Cannot Be Edited


Created By: Simranjit Rai On 07/24/2024 at 04:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARQUEZ LIVING I (RCFE)
FACILITY NUMBER: 435202655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2024
Section Cited

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87411Personnel Requirements - General (a)Facility personnel shall at all times... competent to provide the services necessary to meet resident needs....
This requirement is not met as evidenced by:
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Based on record review and interview, resident R2's medications did not have physician order and staff, including ADM were administering medication to R2 which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
07/25/2024
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.
This requirement is not met as evidenced by:
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Based on observation and interview, resident bathroom had tile lifting from the floor and power outlet was not covered, exposing electric wires on the wall which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 07/25/2024 08:28 AM - It Cannot Be Edited


Created By: Simranjit Rai On 07/24/2024 at 04:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARQUEZ LIVING I (RCFE)
FACILITY NUMBER: 435202655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2024
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... interfering with daily living functions such as eating, sleeping, or elimination.
This requirement is not met as evidenced by:
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Based on observation and interview, the ktichen door was locked with a key pad lock and residents were not able to access food and water supply which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type A
07/25/2024
Section Cited

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
This requirement is not met as evidenced by:
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Based on record review, interview, and observation, ADM stated she is "vaguely familiar with Title 22" and did not receive complete training when obtaining Administrator Certification a year ago which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 07/25/2024 08:28 AM - It Cannot Be Edited


Created By: Simranjit Rai On 07/24/2024 at 04:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARQUEZ LIVING I (RCFE)
FACILITY NUMBER: 435202655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2024
Section Cited

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87205 Accountability of Licensee Governing Body (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility...
This requirement is not met as evidenced by:
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Based on record review, interview and observation, Licensee did not supervise the facility staff including the Administrator to conform with regulations such as Title 22 and Health & Safety Code which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 07/25/2024 08:28 AM - It Cannot Be Edited


Created By: Simranjit Rai On 07/24/2024 at 04:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARQUEZ LIVING I (RCFE)
FACILITY NUMBER: 435202655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2024
Section Cited

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1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios.
This requirement is not met as evidenced by:
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Based on record review and interview, the ADM conducted last disaster drill on 1/2/2024 and ADM will schedule another drill soon which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
07/31/2024
Section Cited

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87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
This requirement is not met as evidenced by:
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Based on record review and interview, ADM did not have facility staff training at the facility and could not provide records of staff trainings during today's visit which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 07/25/2024 08:28 AM - It Cannot Be Edited


Created By: Simranjit Rai On 07/24/2024 at 04:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MARQUEZ LIVING I (RCFE)
FACILITY NUMBER: 435202655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2024
Section Cited

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87623 Indwelling Urinary Catheter (b)(2)(B) There shall be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed.
This requirement is not met as evidenced by:
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Based on record review and interview, ADM stated facility staff were verbally trained by Home Health agency but did not document the instructions and training regarding emptying the bag which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
07/31/2024
Section Cited

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87608 Postural Supports (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
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Based on record review, obserbation and interview, 2 out of 12 residents using half-bed rails for mobility did not have signed written physician's order in resident's file which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
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